Each year, more than a million young women under the age of 21 in the United States are getting medically unnecessary pelvic exams and Pap tests, according to a study published in JAMA Internal Medicine.
The unwarranted exams and tests are not only costing the U.S. economy an estimated $123 million a year, they are also putting young women in line for potential harm. As the study’s authors point out, these medical procedures can result in false-positive results, which in turn can lead to overdiagnosis and overtreatment, including surgery.
Just a decade or so ago, pelvic exams were given to all women at their annual medical checkup to screen for sexually transmitted infections (STIs). A Pap test was also given annually to screen for cervical cancer. Those practices are no longer recommended, however, because it turned out that there was no scientific evidence to support them.
Leading medical groups, including the American College of Obstetricians and Gynecologists and the American Cancer Society, now say pelvic exams are unnecessary for nonpregnant women who have no symptoms of an STI. They also say that Pap tests are unnecessary for women under the age of 21 who are symptom-free and not infected with HIV. After that age, the groups say, routine Pap tests should continue only every three to five years until age 65, when they can stop for most women.
But many doctors and other health care professionals have been ignoring these updated recommendations. The authors of the current study decided to take a look to see how many young women — those under the age of 21 — are still receiving pelvic exams and Pap tests and what proportion of those tests are potentially unnecessary.
Gathering the data
To conduct the study, the researchers used data collected from 3,410 young women aged 15 to 20 who participated in the government-run National Survey of Family Growth between September 2011 and September 2017. The survey, which is conducted in person by trained interviewers, asked the young women a variety of health-related questions, including whether they had undergone either a pelvic exam or a Pap test within the past 12 months.
The researchers classified the pelvic exams as either medical necessary or medically unnecessary. The exams were considered necessary if they were done because the young woman was pregnant, or using an intrauterine device (IUD) for birth control, or had symptoms or a diagnosis of an STI.
Because Pap tests are not recommended for women under age 21 (except for those who are infected with HIV and sexually active), all tests given to the study’s participants as part of a routine health exam — which turned out to be about 70 percent of them in this study — were categorized as unnecessary.
Based on the survey data, the researchers estimated that almost a quarter of young women aged 15 to 20 in the United States, or 2.6 million, receive a pelvic exam each year. More than half of those exams, or 1.4 million, are potentially unnecessary.
The researchers also estimated that about a fifth of young women aged 15 to 20, or 2.2 million, receive a Pap test each year and that three quarters of those tests, or 1.6 million, are potentially unnecessary.
Almost all (97 percent) of the potentially unnecessary Pap tests were performed during the same health care visit as the potentially unnecessary pelvic exams.
The study also found that young women who were using birth control pills or other hormonal forms of contraception other than the IUD were 31 percent more likely to have a pelvic exam and 75 percent more likely to receive a Pap test than those not using those forms of birth control — despite the fact that current recommendations clearly state that neither procedure is necessary in such a situation.
Race and ethnicity were not found to be associated with receiving a pelvic exam, although, interestingly, the study did find that women with public or no health insurance were about a third less likely to receive the exam than those with private insurance.
Limitations and implications
The major limitation of this study was its reliance on self-reported information. Although the survey’s interviewers used detailed descriptions of pelvic exams and Pap tests when asking about them, the young women’s recall of whether or not they had the procedures may not have been entirely accurate.
Also, the medical information used to determine whether the two procedures were medically necessary or not may have been incomplete in some cases.
Still, the results support the findings of previous research. In a 2013 survey, for example, 87 percent of U.S. obstetricians and gynecologists said they would perform a pelvic exam on an 18-year-old woman with no symptoms of an STI.
Such attitudes can lead to harm, as an editorial that accompanies the study stresses.
“Some have suggested that the benefit of requiring an annual pelvic examination is that it prompts women to visit a clinician for their annual examination. There is no evidence to support this hypothesis,” writes Dr. Melissa Simon, a professor of obstetrics and gynecology at Northwestern University a member of the USPSTF, in the editorial. “In fact, many women (younger and older) associate the bimanual pelvic and speculum examinations with fear, anxiety, embarrassment, discomfort, and pain. Girls and women with a history of sexual violence may be more vulnerable to these harms. In addition, adolescent girls may delay starting contraception use or obtaining screening for sexually transmitted infections because of fear of pelvic examination, which thus creates unnecessary barriers to obtaining important screening and family-planning methods.”
The current study demonstrates “what happens to vulnerable populations (in this case, girls and young women) when clinicians do not keep up with or do not adhere to new guidelines,” she concludes.
FMI: You’ll find an abstract of the study on the JAMA Internal Medicine website, although the full study is behind a paywall.
NOTE: This article has been edited to remove the inclusion of the U.S. Preventive Services Task Force (USPSTF) from the list of organizations that say pelvic exams are not necessary for average-risk asymptomatic women who are not pregnant. The USPSTF did not find enough information to recommend for or against such exams in that group of women. Instead, they called for more research.